《心肺复苏-电除颤.ppt》由会员分享,可在线阅读,更多相关《心肺复苏-电除颤.ppt(35页珍藏版)》请在三一文库上搜索。
1、,Cardio-Pulmonary Resuscitation,Defibrillation,2019/6/30,心肺复苏的生存链,电除颤,电除颤是以一定量的电流冲击心脏从而使室颤终止的方法。 是治疗心室纤颤的有效方法,现今以直流电除颤法使用最为广泛。,动力学不稳定或药物控制不佳的患者,电除颤的并发症,2010 AHA guideline,首次除颤的时间? 除颤电板的选择? 除颤波的波形和能量应该如何选择? 特殊情况下应该如何除颤?,7,Herlitz, Johan, et al. Resuscitation 34.1 (1997): 17-22.,8,CPR before defibrill
2、ation?,Preintervention: immediate defibrillation Intervention period: 90-sec CPR protocol,L. A. Cobb, et al. JAMA 281, 1182-1188 (1999),早期行CPR(90s内)能改善心肺复苏后患者的预后和远期生存率。,9,L. Wik, et al. JAMA. 289, 1389-1395 (2003).,Standard: immediate defibrillation CPR first: CPR within the first 3 mins,早期行CPR并不能改善
3、生存率和预后。,10,心脏骤停后的三个时相理论,电时相:心脏骤停4min内,除颤效果最好 循环时相:4-10min内,心肌已经有较长时间没有血氧供,单纯除颤成功机会较少,应先进行按压,恢复心脑的血氧供应,再考虑除颤 代谢时相:10min以后,机体因长时间缺血缺氧,产生大量的代谢因子,复苏成功率较低,Recommendation,There is inconsistent evidence to support or refute delay in defibrillation to provide a period of CPR (90 seconds to 3 minutes) for pa
4、tients in non EMS witnessed VF/pulseless VT cardiac arrest. 目前没有一致的证据来支持或者驳斥延迟电除颤以行即时CPR(90s-3min)在心肺复苏中的确切效果。 目前最推荐的做法是立即行CPR,同时尽快除颤(90s-3min内)。,2010 AHA guideline,首次除颤的时间? 除颤电板的选择? 除颤波的波形和能量应该如何选择? 特殊情况下应该如何除颤?,13,除颤-电极位置?,默认电极:前-侧位,三个位置 (前-侧位效果最佳,其次为前-后位及心尖后位) 避开植入装置,Kirchhof P, et al. Lancet 200
5、2; 360: 1275-1279.,15,Recommendation,It is reasonable to place paddles/pads on the exposed chest in an anterior-lateral position. Acceptable alternative positions are anterior-posterior (for paddles/pads) and apex-posterior (for pads). 推荐除颤时把电极板放在患者暴露胸部的前侧位,次选的位置有前后侧(电极片/板)以及心尖后侧(电极片),电极板的大小?,Kerber
6、 RE, et al. Circulation 1981; 63: 676-682.,推荐电极板与患者的接触面积8cm。,17,2010 AHA guideline,首次除颤的时间? 除颤电板的选择? 除颤波的波形和能量应该如何选择? 特殊情况下应该如何除颤?,双相120-200J,单相360J,儿童首剂2J/kg,后续4J/kg (10J/kg,成人最大量),单相波 vs 双相波,双相波优于单相波。,双相波并不优于单相波。,Recommendation,Biphasic waveforms are more effective in terminating VF when compared
7、with monophasic waveforms. There is insufficient evidence to recommend any specific biphasic waveform. In the absence of biphasic defibrillators, monophasic defibrillators are acceptable. 在室颤时,双相波明显优于单相波,但没有充分证据来证实哪种波形更有效。在没有双相波的情况下,单相波可作为替代选择。,4个RCT研究,Termination of ventricular fibrillation after f
8、irst shock,Return of spontaneous circulation,Return of organized rhythm after first shock,综上,双相波在除颤中并不优于单向波。,双相波形的选择,Biphasic Truncated Exponential (BTE) Waveform. Pulsed Biphasic Waveform. Rectilinear Biphasic Waveform.,27,心肌损害,150J的双相波对心肌的损害最小。,Walcott GP, et al. Prehosp Emerg Care. 2010;14:6270.,
9、28,与150J双相波相比,360J单相波不会引起更多心脏损伤。,Walcott GP,et al. Prehospital emergency care. 2010; 14: 62-70.,29,Recommendation,It is reasonable to start at a selected energy level of 150 J to 200J for a BTE waveform for defibrillation of pulseless VT/VF cardiac arrest. There is insufficient evidence to determine
10、 the initial energy levels for any other biphasic waveform. Although evidence is limited, because of the lower total shock success for monophasic defibrillation, initial and subsequent shocks using this waveform should be at 360 J. 双相波除颤的能量应为150-200J,单相波除颤的初始剂量应为360J。,除颤能量与预后,Fixed lower-energy: 150
11、-150-150J; Escalating higher-energy: 200-300-360J.,Stiell IG, et al. Circulation 2007; 115: 1511-1517.,31,这些研究结果表明,如果患者需要除颤,那么较高的能量更有益于患者的预后。,32,2010 AHA guideline,首次除颤的时间? 除颤电板的选择? 除颤波的波形和能量应该如何选择? 特殊情况下应该如何除颤?,33,特殊情况,有植入型心律转复除颤器(ICD)或心脏起搏器的患者 立即除颤 两个除颤电极板/片之间的距离应该8cm 电极板的位置可以选择前-后位和前-侧位,34,小结,心脏骤停/室颤的院内急救: 先进行胸外心脏按压,并尽快除颤; 立即接心电监护,室颤到给予电除颤时间3min。,Thank you for your attention!,
链接地址:https://www.31doc.com/p-3050413.html